Every day I experience life in the world of healthcare IT, supporting 3000 doctors, 18000 faculty, and 3 million patients. In this blog I record my experiences with infrastructure, applications, policies, management, and governance as well as muse on such topics such as reducing our carbon footprint, standardizing data in healthcare, and living life to its fullest.

Monday, June 30, 2008

I was recently asked how outpatient prescriptions and over the counter medications are bar coded and how inpatient medications should be bar coded if they are repackaged.

Here's the overview.

Some outpatient prescriptions and most over the counter (OTC) medication package bar coding today use the 12 digit UPC-A bar code symbology. The OTC bar code may contain the NDC number or the Universal Product Code (UPC) number for the product.

Many outpatient medications that have the UPC number in the bar code also have a 10 digit National Drug Code number printed on the package (usually placed near the drug name) , in a 3 part format separated by dashes i.e xxx-yyy-zzz (where xxx=manufacturer, yyy=product, zzz=package size). A company called RxScan has created a database which crosswalks UPC-A bar codes and NDC numbers, enabling applications to be built which use bar codes to check drug safety.

Inpatient medications must contain the 10 digit NDC number embedded in the bar code itself per the FDA regulations specifying the bar code format .

The reason I was asked this question is that in FY09 we will implement electronic Medication Administration Records which depend on scanning a bar code on the unit of use package. In FY08, we set as a goal that at least 70% of drugs that we procure from vendors or which we repackage ourselves will have a bar-code on the unit-of-use drug package. During our mid-year physical inventory we took a snapshot and determined that over 90% of the unit-of-use packages we dispense have barcodes on them. 24% of these were RSS-stacked format, 8% were data matrix and 68% were single-line linear bar codes. However, we have not yet verified the readability or the content of those bar-codes, and we are not yet scanning all medications prior to administration to patients or upon filling automated dispensing cabinets (ADCs). We are barcoding certain high-risk medications upon filling ADCs in the NICU (e.g. heparin, digoxin, vitamin K) and hospital-wide for ADC-refrigerated, compounded narcotic-containing bags and syringes (for verification by RN upon removal from the ADC refrigerator because they can look alike).

Our efforts in FY09 will include documenting all the workflow redesign and new devices we need to deploy to support electronic Medication Administration Records. I'll document all these efforts on my blog!

Although the study focused on RFID tags, the issue is more generic. Electronic Magnetic Interference (EMI) is generated by many devices including cell phones, laptops, and microwave ovens. Such devices emit RF energy which may interfere with the operation of sensitive electronic components used in medical equipment. The interference may be frequency related (signal jamming) or cause the device to fail because a chip or wire is exposed to too much energy from an emitting device. The very best defense is to have adequate shielding for medical equipment. It's inconceivable that hospitals can keep patient care areas free of RF emitters. Thus, it is important for hospital Clinical Engineering departments to be constantly vigilant in identifying potentially unsafe devices.

CareGroup addressed this issue 7 years ago with a global EMI guideline and summary, which we developed by inviting 100 industry experts and the FDA to a consensus conference in Boston.

Of course, we continue to test new EMI emitting technologies as they are introduced into the hospital. Our RFID use is well documented. The Active RFID tags deployed at BIDMC have been tested by Clinical Engineering for interference with other hospital devices and do not cause a problem.

In addition to thinking about the risks of new technologies, we should also consider the benefits. Remember that every activity in life has a risk (which I measure in Morts). If the risk of patient harm is 1 in a million, but the benefit of using the technology prevents harm to every patient, the hospital needs to carefully assess the balance. In the case of RFID, we have deployed the technology with significant testing and adherence to our guidelines, mitigating the risks and maximizing the benefits.

In Wellesley, there is no garbage service. Every household sorts their waste into these categories and drives to the recycling and disposal facility (the RDF). It's a social occasion. I'm likely to meet Fidelity Vice Presidents, McKinsey Partners, and Venture capitalists while dropping my recyclables into the appropriate bins. People meet, have romances, and get married at the RDF (true story!).

Each week, after dropping off all my recycling, I have just a few pounds of waste left over. That, we compost. We have two types of compost bins - a compost tumbler in the yard and a compost pail for the house to collect and transport kitchen scraps to the compost tumbler. Since our household is all vegan, we have no grease or meat waste at all, so we never have issues with attracting wildlife or rancid compost.

One really handy area of the RDF is the "Take or Leave it" area. Whenever we have items in the attic, garage or basement that still have a useful life but are no longer needed, we take them to the RDF where others can take them at no charge. It's a kind of town-wide Yankee swap system.

Just a few hours each week by the 5000 households in the town reduces our solid waste by 90% and generates $2 million in revenue for the town through the sale of recyclable materials.

Reduce, Reuse, and Recycle - it's a great way to be green in your neighborhood.

Wednesday, June 25, 2008

Time is the one commodity you cannot buy and you cannot make more of. To me, this means that time is our most valuable resource.

The role of the CIO to allocate their time to those people and projects most needing of attention.

Every day, I would really enjoy meeting with friendly, aligned and supportive stakeholders. I would really enjoy focusing on those projects that are proceeding flawlessly. However, my most limited commodity, time, is best allocated toward those stakeholders who are not satisfied and those projects which are troubled by politics, scope, or technical challenges.

Every day, my staff ask for help with budget issues, strategy clarification, and political questions. The CIO should never be the rate limiting step. I answer these questions within an hour of their being asked with either an answer or a definite set of next steps. This is a great use of my time.

Every day, my customers ask for new projects, new priorities, or new features. I answer with either a blog entry so that I widely communicate the answer, a personal email, or a set of next steps involving our governance committees to consider the request. This is a great use of my time.

Every day, I receive numerous requests to travel to give presentations to organizations both large and small. I'm always happy to educate, communicate, and collaborate. The challenge is the time involved in travel. Doing a conference call, webex, or video teleconference is a great use of time. Sitting in an airport for half a day because of a canceled flight is not a great use of time. I'm hoping our culture changes to the point that everyone thinks about the value of time and does more virtual collaboration.

Every day, I receive a 100 requests from salespeople for my time. Money is one thing you can always make more of. Time is limited. As I've said before on my blog, I will not grant my time to cold calling salespeople who email me about the wonders of their product. Stop trying. As needs arise I'll search the web for technologies and user experiences with them. I'll then contact you.

The reason that I mention this entire subject is that recently I reflected on the best gift for Father's day. Anyone can buy a tie, a CD on Amazon, or the latest gadget. However, the gift of time is more valuable. Here's what I did.

I had a Google Advisory Council meeting in Mountain View from 8a to 1pm. My parents live in Southern California. I asked my father to meet me at the San Jose Airport at 2pm and I picked him up in my rent a car. We drove together through the most beautiful places in the Santa Cruz mountains - Crystal Springs Reservoir/Filoli/Alpine Road, Highway 84 to Skyline Boulevard in the Santa Cruz mountains, La Honda, San Gregorio, Highway 1 to Pigeon Point Lighthouse, and Pescadero. We had dinner at Duarte's, a 19th century restaurant which serves fresh artichoke dishes and homemade pie. We talked about life, goals, the future, family, and challenges. For 6 hours, we drove, talked, and turned off the cell phones. At sunset we returned to Skyline Boulevard (photo above) and played flutes together - my Shakuhachi and his Native American Flute. I then dropped him off at the airport for his return flight and I spent the night in San Francisco to attend an early morning Board meeting.

My daughter and I recently began playing the Native American Flute, so that we can have a family gift of time. My parents will join us on family vacation to Yosemite in August and we'll play music together across 3 generations.

To me, there is no more profound gift than time. If future Father's Days include the gift of time from my daughter such as a walk in the woods, kayaking a river, or playing a flute, I'll be completely happy.

Next time you ask how to organize your day, think about the value of your time. Think about the needs of your customers, staff, and family. If you think about your time as a gift and your most valuable commodity, I suspect your schedule may change. I know mine has.

Tuesday, June 24, 2008

At times, the business case for interoperability is not entirely clear. If data sharing reduces the volume of redundant lab tests, then the healthcare system as a whole wins, but someone loses revenue.

Over the past year, I've seen a remarkable change in attitude among clinicians in Massachusetts communities. They are demanding data sharing. Here's the history, the specifics of the clinician requests, and the plan for making it happen.

When we first conceived our hosted software as a service model to provide electronic health records for non-owned clinicians, we designed one way interoperability. BIDMC has an ambulatory record called webOMR which contains the problem lists, medication lists, allergy lists, notes/reports, labs, and imaging studies for 3 million patients. We worked with our community EHR vendor, eClinicalWorks, to create a seamless web service that links eClinicalWorksto webOMR such that community physicians can securely view BIDMC data from inside eClinicalWorkswithout having to login again or use a separate application. However, we did not design a link between eClinicalWorksand webOMR to enable a BIDMC hospitalist or ED physician to view individual patient identified private practice data.

We did design aggregate data sharing such that the medical director of the Physician's organization could query private practices to retrieve performance, quality and outcomes data in support of pay for performance contracts.

As we began to communicate the vision of a community EHR, our private practice clinicians starting asking three questions:1. How does a Primary Care Provider send a clinical summary to a Specialist?2. How does the Specialist close the loop with the Primary Care Provider by sending an electronic consult note?3. How does a hospital-based physician such as an Emergency Department clinician, hospitalist, or anesthesiologist retrieve patient summary records from private practices?

My initial response was that private practice data sharing is such a novel idea, that it would have to wait until after our EHR rollout was complete to formulate a strategy.

Clinicians were not satisfied with that approach. Thus, we've decided to accelerate our work on private practice data sharing sharing by creating a clinical summary repository for all our eClinicalWorksusers using the eClinicalWorks EHX product.

Here's how it will work.1. Whenever a patient visits one of our BIDPO community clinicians, the documentation of their visit will be done in our hosted software as a service eClinicalWorksapplication.2. Patients will be consented by the clinician for community data sharing via opt in consent at the practice level. Consenting at one practice implies that data from that practice can be shared with other practices, but not visa versa. 3. When the encounter is complete, a summary record including problems, medications, allergies, notes, and labs will be forward to the eClinicalWorks EHX repository using the Continuity of Care Document format.4. Other clinicians, who are credentialed members of BIDPO will be able to view summary records from this repository, assuming the patient has consented to sharing that data.5. An audit trail of all such lookups will be available to enforce security

Such an approach solves the PCP to specialist clinical summary issue, the specialist to PCP communication issue, and the hospital-based viewing of private practice records issue. From a technology perspective, it's an elegant solution that reduces the number of interfaces. All practices send their summaries to a repository in a standard format, then all exchange is done from that repository.

A similar approach has been used in the Massachusetts eHealth Collaborative pilots in North Adams, Newburyport, and Brockton to enable secure, patient consented data sharing in those communities.

This approach needs one additional architectural element - how do you share data among EHX repositories, with non-eClinicalWorks EHRs or hospital information systems like Meditech.

MA-Share provides the grid infrastructure in Massachusetts to enable community to community data sharing. Today, MA-Share's Gateway can push Continuity of Care Document Summaries from one organization to another. Over the next two years, we'll work with eClinicalWorks to expand this capability to push clinical document summaries between instances of EHX. This means that BIDMC will be able to push a discharge summary or other clinically important information to a community repository, where with patient consent, the clinicians of a community caring for the patient will be able to view the data, ensuring continuity of care.

I expect all of this bidirectional data sharing to be a journey. We're purchasing the EHX product as part of our licensing of eClinicalWorks software and will use it initially for performance reporting. But we'll configure it so that sharing of data between clinicians and among communities will be possible. I expect all these features to be implemented by 2011.

I'm hopeful that our BIDPO clinicians will be satisfied by our strategy to embrace bidirectional data sharing in this incremental way - sharing data from BIDMC, sharing aggregate private practice data, sharing data among private practices using eClinicalWorks, then sharing data among communities and hospitals.

1. A single point of entry for our built applications (or as few entry points as possible) would be ideal. The challenge is making this single point of entry default by person or location such that the entry view would be the inpatient dashboard, provider schedule, Emergency Department dashboard, or patient name lookup.

2. Having our departmental systems such as Anesthesia Information Management, Cardiology/EP, Metavision ICU Management, and Gcare Endoscopy documentation generate a PDF or summary accessible in one place would be ideal. Doctors will know that all the reports they need will be in one place, including highlights or abstracts of key information to speed the decision-making where possible.

3. Workflow analysis is important and should be completed before applications are coded. In FY09, Healthcare Quality will do the workflow analysis for "Who's the Caregiver", so that the first clinicial to call 24x7x365 is known for every patient. IS will do the workflow analysis on discharge worksheets with an eye toward smaller, short term enhancements in FY09 and more extensive redesign at a later point. Operations impact analysis should also accompany planned implementation. For example, electronic medication administration records may have capital needs such as bedside scanning. Operational and capital budgets should be approved and synchronized.

4. The discharge summary needs a comprehensive multi-stakeholder inventory. This needs assessment and policy should be done by the HIM committee. Once it is complete we can determine which data elements should flow from existing data sources and which should be entered by the clinician to achieve a "cognitive" overview of the patient's care.

5. Scanning should be used for charts/graphs/forms which are challenging to automate. Some forms, such as the medication administration record, have high clinical value and comprise a significant part of the record. Development of Medication Administration Record automation will begin in FY09 as part of our self built applications.

6. A problem oriented medical record requires histories/physicals and progress notes that include a robust community-wide vocabulary controlled problem list as part of their documentation design. These applications will be built rather than bought and will incorporate text entry/templates/macros. Introduction of controlled vocabularies for problem lists will be done via a phased, incremental approach. Team Census will be enhanced to become the daily documentation tool for progress notes.

7. Certain guiding principles should be included in our build and buy implementations - multidisciplinary, integrated, non-repudiatable, secure and web-based where possible.

8. Decisions between homegrown or vended products should consider the specific demands of an individual application and also the downstream impact of vended systems for other providers. Whenever possible we should use our existing applications.

9. Policies are needed to compliment our software rollouts. The HIM committee will suggest the policies and we will work together with the MEC to formalize policies and performance metrics as rollouts occur

10. We will review our plans with all our governance committees and stakeholders to ensure buy in for our approach.

Friday, June 20, 2008

In the days of TDMA cell phones, BIDMC was an early innovator with in-building cellular communications. We worked with AT&T and Ericsson to install their Digital Wireless Office Services (DWOS), which enabled employee cell phones to roam on our internal cellular network. Here's how it worked.

Imagine that a employee drove from home and made a call from their personal cell phone. That call travelled over the AT&T network, was paid for by the employee and used the 7 digit phone number on their cell phone. As the employee walked into a Beth Israel Deaconess building, control of the phone was transferred to the internal cellular system. Calls were routed through the PBX, the hospital paid for the calls via its negotiated rates, and standard hospital 5 digit dialing worked to and from the phone. Anyone calling the employee's desk phone was routed to the cell phone.

Now, a new generation of products which converges fixed desk phones and mobile phones (called Fixed-Mobile Convergence) is emerging. The idea is similar to DWOS. Employees carry one device that serves as their mobile and desk phone. This one device is seamlessly integrated into the PBX. The infrastructure provides low cost voice connectivity while on campus by avoiding cellular charges. It's the Cool Technology of the Week.

AgitoNokia/Symbian phones (the only phones currently supported) run an Agito client which determines how best to connect to the Agito server that is connected to your enterprise PBX and your enterprise data network. Agito also interfaces to Cisco's Call Manager, providing device monitoring and management via the Session Initiation Protocol (SIP)

DiVitas Windows Mobile or Nokia/Symbian phones run a DiVitas client which uses Environment Aware Roaming Technology to switch between a WiFi or Cellular carrier and connect back to a DiVitas server appliance connected to the enterprise PBX.

The technology is cool and promises one device connectivity, eliminating the desktop phone. The downside is that few handsets are currently supported (i.e. my Blackberry 8320 has WiFi and GSM/GPRS/EDGE but cannot run with Agito or DiVitas). Also dual mode phones really drain the battery when in WiFi mode.

This is a technology to watch, since I believe in a parsimony of gadgets. Getting rid of my desk phone would be great.

There are three basic types of patients who I treat via Regional Poison Control Centers referrals:

1. Toddlers - 2 to 4 year olds wander out to the lawn and munch a mushroom. They usually eat small quantities and most often parents find unchewed pieces in their children's mouths. Common mushroom types are the Fairy Ring pictured above (Marasmius oreades) and "little brown mushrooms" (Mycena), both non-toxic. I generally try to avoid treating toddlers with activated charcoal, the common treatment for poisonings, by rapidly identifying the mushroom as non-toxic. My experience with activated charcoal in pediatric poisoning is that more charcoal ends up all over the parents than in the patient.

2. Teenagers - 14-18 year olds who search cow pastures looking for blue-staining mushrooms i.e. "Hey man, do THOSE shrooms grow around here?" Yes, various hallucinogenic mushrooms grow in New England - Psilocybe species, Panaeolus, and Amanita Muscaria abound. The challenge for these teenagers is that these mushrooms contain wildly variable amounts of toxins. One mushroom may contain virtually no toxin and another may contain an overdose. I remind teenagers that "intoxicate" contains the word "toxic". The treatment for overdose of hallucinogens is largely supportive - a quiet dark place and the use of anti-anxiety drugs to treat a truly bad trip.

3. Gourmets - the 20+ educated amateur mushroom hunter with an Audubon field guide who looks for mushrooms based on pictures in the book. There are 2500 species of mushrooms in North American, of which 35 are great to eat and a dozen are lethal. Edible mushrooms and toxic mushrooms can look similar. A mushroom expert considers the time of year, where the mushroom is growing, and trees growing near the mushroom when picking edible mushrooms. A photo from a field guide is really not that helpful. The only deaths I've had in my consulting practice are the Gourmet amateur mushroom hunters. A typical story is that an educated person picks two pounds of wild mushrooms, makes stroganoff, gets ill 12 hours later, waits a few days, feels better, then suddenly develops seizures, liver failure, kidney failure and seeks medical care. By that time it's too late and not even liver transplant works. If you want to pick mushrooms to eat, learn from an expert how to identify a few key species such as morels, chantrelles, and porcini. Learn where they grow and pick them from the same patch year to year. Avoid eating any mushrooms with white gills (the underside of the cap). Not all white gilled mushrooms are poisonous, but Amanitas are white gilled mushrooms that can kill you.

How am I consulted? Today, I've received 4 consults already. Doctors throughout New England call Poison Control Centers, which refer callers to me. The doctors use their cell phones to take pictures of the mushrooms and patients, then email them to me. On my Blackberry, I can view the mushroom, determine the species, outline a course of treatment and followup with the patient to ensure all is well.

Mushroom Season runs from June to October in New England. Based on the volume of incoming consultants, I can tell it's going to be a busy year!

Wednesday, June 18, 2008

Next week, I'm meeting with the BIDMC Board's Patient Care Assessment and Quality Committee (PCAC) to discuss the 2009 tactics for improving quality with information technology. The overall presentation includes 2008 accomplishments, 2009 goals, the national context, and our general approach. I've chosen to communicate the specifics in the context of the Joint Commission's 2008 Patient Safety Goals. Those goals and our projects are below:

Goal 2 Improve the effectiveness of communication among caregivers.2A For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the information record and "read-back" the complete order or test result.IS Projects: Live with provider order entry in all locations except NICU and ED, which are 2009 projects

2B Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization.IS Projects: Library Services and HIM have produced this list and widely circulated it

2C Measure and assess, and if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values.IS Projects: Live with Results notification

2E Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.IS Projects: Discharge summary push live, enhancements to team census and discharge in 2009

Goal 3 Improve the safety of using medications.3C Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs.IS Projects: Decision support databases for medication safety are updated monthly

3D Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field.IS Projects: Positive ID of medications with bar codes complete for 90% of medications

3E Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.IS Projects: POE supports evidence-based ordering of Heparin and standard dosing for warfarin, with latest relevant laboratory values.Web OMR flow sheet supports tracking of INR values over time and from multiple sites.

Goal 7 Reduce the risk of health care-associated infections.7A Comply with current World Health Organization (WHO) Hand Hygiene Guidelines or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.IS Projects: Desktop screensaver about hand washing is live

7B Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection.IS Projects: Incident reporting and Adverse event reporting applications are live

Goal 8 Accurately and completely reconcile medications across the continuum of care.8A There is a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization.IS Projects: WebOMR medication list has become designated source of truth regarding patient’s medications and is used across all specialties. It is now in pilot for integration with inpatient history and med reconciliation and POE ordering

8B A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the facility.IS Projects: Within BIDMC, WebOMR medication list is used by all. Outside BIDMC MA-Share push pilot sends an electronic list of discharge medications to the next provider of care. Our e-Prescribing infrastructure includes a lifetime medication history from retail pharmacies and payers

Goal 9 Reduce the risk of patient harm resulting from falls.9B Implement a fall reduction program including an evaluation of the effectiveness of the program.IS Projects: Electronic nursing Kardex includes risk factor capture and calculation of Morse Score for patient’s risk of fall. Elevated scores trigger RN to request MD get a physical therapy consult. Fall risk is also available on unit dashboard (the graphic above)

Goal 13 Encourage patients’ active involvement in their own care as a patient safety strategy.13A Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so.IS Projects: Patients can access their entire health record via Patientsite, Google Health or Microsoft Healthvault

Goal 15 The organization identifies safety risks inherent in its patient population.15A The organization identifies patients at risk for suicide.IS Projects: Decision support databases are available for data analysis of diagnoses, labs, medications, radiology, pathology, and microbiology

Goal 16 Improve recognition and response to changes in a patient’s condition.16A The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening.IS Projects: New ICU system supports triggers and decision support based on clinical rules.

I'll also include a discussion of governance so that all understand how the stakeholders, including the Board, set the priorities for the work we do.

Tuesday, June 17, 2008

As we implement EHRs for BIDPO practices, several clinicians have expressed concern about the loss of productivity during the first few months post go live.

What's been the experience for private clinicians implementing EHRs in Massachusetts thus far? The Massachusetts eHeath Collaborative implemented 600 clinicians over the past 3 years and generally found:

1. There was not a sustained drop in revenue. Indeed, clinicians had the opposite problem with most practices. MaeHC wanted practices to cut back on patient load during training and go-live, but most of them refused because they didn’t want a revenue reduction. On eClinicalWorks, most practices that did cut back were back at full-patient load within 2-4 weeks of go-live. MAeHC did have a few (literally 3 or 4 out of 150) practices who experienced a cash flow reduction because their clearinghouse transition went awry (generally due to the clearinghouse vendor). This usually took a short time to resolve and then they were quickly back to baseline.

2. During the first few months after go-live clinicians worked harder than before because they entered selected historical data into their EMRs for upcoming patients and sometimes staying later to get the same number of visits in as before. After 3-4 months clinicians started seeing some of the same patients cycle through, and that’s when they started to see the productivity benefits of an EHR.

3. The industry averages on productivity loss are for practices who did not have the type of preparation and end-to-end practice consulting that MAeHC and BIDMC invested in. For the BIDPO rollout, we are leveraging the practice transformation lessons learned from MAeHC. Based on the experience the MaeHC has had and the fact that we've assembled an implementation dream team of the same folks who implemented the 600 docs of MAeHC, we do not believe we will have a significant reduction in billing or productivity.

Monday, June 16, 2008

I was recently asked how we ensure Advanced Directives and Healthcare Proxies are broadly communicated to all caregivers at BIDMC, among all stakeholders in Massachusetts, and how they could be communicated throughout the country.

At BIDMC, our inpatient record enables providers to enter advance directive details and document specific orders in provider order entry. Per hospital policy, Do Not Resusitate orders entered as an inpatient expire at discharge and must be rewritten on subsequent admissions. All advance directives are displayed on our hospital dashboards (see screenshot above), so all caregivers are notified of all patient preferences. These dashboards are the entry point to all our Provider Order Entry and inpatient functions, so all caregivers use them.

At BIDMC, our ambulatory and inpatient record support a shared Health Care Proxy function. The proxy function enables users to enter the patient's proxy information and its details, the proxy name and contact information, and a free text comment. Proxy information is displayed in both the ambulatory and inpatient profiles.

Nationally, the HITSP interoperability specifications for clinical summaries include advance directive information. For an example, see my lifetime medical record.In the future, I imagine that personal health records such as Microsoft HealthVault and Google Health will support Advanced Directive and Healthcare Proxy data sharing. BIDMC will continue to work with Google, Microsoft and other PHR providers to support such functions.

Friday, June 13, 2008

I'm often asked what tools and technologies we use to manage our 425 Terabytes storage infrastructure (almost half a Petabyte). What's cool about this array of hardware and software is that it works so well. We've not had downtime in 5 years, we've kept up with customer demand, and we've been able to meet our budget/green initiative goals despite significant increases in demand for storage capacity. Here's the overview.

1. Symantec Netbackup - Used to move all files into backup and archival storage.

2. Akorri Balance Point - Used with our Clariion storage to monitor disk contention and hotspots, recommend best placement of data, and where to get best performance bang for buck (e.g. add spindles, cpu, or memory?).

3. NetApp Onaro SanScreen Foundation and Capacity Manager - Provides means for server team to make provisioning requests, checks configuration changes to make sure they are being done correctly, and flags errors.

4. EMC Control Center and Storage Scope - Used for provisioning Symmetrix and reporting utilitization, so we can ensure our most expensive tier of storage is used most efficiently.

5. EMC Backup Advisor for Data Recovery Management Reporting - Gives us a report card of how we are doing with all clients for backups,how fast each client is etc. It greatly helps us at focusing tuning of the backup environment and ensuring we haven't missed anything.

Of note, the Data Domain appliance is used to efficiently compress and de-duplicate archival data. It has worked very well and been quite cost effective. We've not found another vendor with such a good archival storage product. I recommend you read this hilarious blog entry by Data Domain describing the industry reaction to their products.

Finally, we have also introduced Acopia File virtualization into our environment, which enables us to move files among storage devices and storage tiers without having to remap applications, user file shares, or operating system configurations. It's truly made us nimble in the allocation of storage types and locations.

Thursday, June 12, 2008

Between May and October each year in New England, the sum of the water temperature in the Charles River plus the daytime air temperature exceeds 100 degrees, reducing the risk of hypothermia in the case of submersion. For me, that's kayaking season.

At least 3 times a week, on my way home to western suburbs of Boston, I stop at the Charles River Canoe and Kayaking building on the Charles River where the Mass Pike meets 128. I have a season pass and can take any kayak out on the river for my typical 8 mile paddle through the Lakes district to the Moody Street Dam in Waltham. The Lakes district is the site of the former Norumbega Dance Hall, home to the big bands of the 1940's and a very popular wide and shallow canoeing spot for the past 100 years. Of historical note, the local native americans called the region Norumbega after it was visited by the "Norumbegians" in the 1300's. The thought is that Leif Ericson or his Viking compatriots may have navigated up the Charles from Boston Harbor to this location, many years before Columbus 'discovered' America.

The Charles is relatively calm flatwater with few currents. How do you choose a kayak for river kayaking?

Kayak designs are a tradeoff between directional stability and maneuverability, and between stability and speed.

For river travel in flatwater, I choose a highly maneuverable, fast kayak with limited primary stability but good secondary stability. These terms are explained below. The primary boat is a use a the Epic V10 Surf Ski, an 18 inch wide kayak that performs like an Olympic racing kayak, but is slightly more stable. I'm able to maintain 8 mile per hour rowing speeds on the Charles without difficulty. On very windy or choppy days, I choose the Epic 18X, a 20 inch wide kayak with greater stability, that I paddle about 7 miles per hour.

Primary stability refers to the initial stability a paddler feels when they sit in the boat. High primary stability feels very comfortable and reassuring. Wider kayaks with more buoyancy away from the centerline will present more resistance to tipping and thus feel less likely to capsize than a narrow one with less buoyancy away from the centerline. Although wider kayaks are more stable, they are also much slower. A 26 inch kayak is easy for a beginning to use, but challenging to paddle more than 6 miles per hour.

Secondary stability refers to the stability a paddle feels as the kayak approaches capsizing. They may feel initially a bit tippy, but are in fact challenging to capsize. My experience is that a relatively narrow kayak with low to moderate primary stability but excellent secondary stability is the most seaworthy in challenging conditions. Since the Charles is rarely that rough, I'm happy to trade stability for speed.

Longer/narrower kayaks are generally faster but a shorter kayak may be turned more quickly. Olympic K1 racing kayaks are 17 feet long and 16 inches wide. They are so unstable that only an expert paddler can use one, but they are very fast.

The shape of a kayak is defined as

* Symmetrical: the widest part of the boat is halfway between bow and stern. * Fish form: the widest part is forward of the midpoint. * Swede form: the widest part is in back of the midpoint.

Kayaks are very personal and I'll recommend you try many types in many conditions. For me, a season pass to a kayaking center is the most cost effective approach because I do not have to store or transport the boat, I can use a new state of the art kayak every year and test many different designs. Since the kayaks I like best - ultralight Kevlar racing kayaks, are $3000-4000 each, the $250 per year for a season pass to use one as often as I'd like, really works.

One last note about kayaking. Keeping a pace of 8 miles per hour for a sustained paddle up and down the Charles burns a lot of calories. When I first became Vegan 7 years ago, my first sustained exercise was kayaking. My 70 pound weight loss was the result of diet and kayaking. I highly recommend paddling as low impact, high cardio, mentally stimulating exercise. Especially if you use a very narrow, slightly unstable, and fast boat. That certainly keeps your blood pumping!

Wednesday, June 11, 2008

On June 17, 2008, I'm facilitating the annual BIDMC IS retreat about the topic of "the transition to the fully electronic inpatient record". To help us prepare for this retreat, I asked several colleagues if they had a scorecard describing the components of the acute care medical record. The hospitals I asked did not have one handy.

For BIDMC's 2007 Joint Commission visit, we assembled a roadmap of all our medical records and indicated if they were paper, electronic or a hybrid of the two. That roadmap shows all our medical record systems.

Of note, we scan all our inpatient paper records, so they are available online to our medical record coders and our clinicians. Although scanned paper is not really an electronic record, it does mean that we no longer need to request the paper record for many patients. To organize the record prior to scanning, we divide all aspects of record in the way we believe a clinician will want to intuitively access the record.

To help inform our retreat, I asked our Health Information Management staff to create a Pareto diagram that will guide our priorities toward implementing a fully electronic acute care record. The results are

This illustrates that the low hanging fruit to creating an electronic inpatient record are graphs/flowsheets, history and physicals, progress notes, discharge summaries, operative notes, and peri-anesthesia testing. Together, these items account for 85% of the paper record. Here's our strawman plan, based on work in progress

1. The ability to render non-repudiable documents over the legal retention period. Except for those documents we send to fixed content storage (Centerra) and stamp, our electronic medical record content is theoretically alterable by a senior system programmer.

2. People must be at least as compliant with electronic signatures as they are with paper document signatures. At present, inpatient document signing (discharge summaries and opnotes) are under good control.

3. The infrastructure underlying a system of record should be disaster proof, or at least as safe as what we do today for paper. Our worst case with paper is a fire in the paper record storage facility. The risk is small as sprinkler protection is in place. We have published service levels for electronic recovery point and time objectives.

4. If we declare an electronic source as the "official" version for that component of the legal record, we should have some policy on when we would produce paper, e.g. only for release to outside entities.

I'll summarize the outcome of our retreat next week which will provide many more details of our plans for FY09 and beyond. Our goal is an 85% electronic inpatient record and transition from a hybrid medical record to an electronic legal record by 2011.

Tuesday, June 10, 2008

Since our community EHR infrastructure is now built we're in an education and communication phase, explaining to clinicians what it does, what it costs, and what they can expect. All our written and verbal communication must be consistent to ensure we set the right expectations. Part of being accurate is a precise definitions of our terms - what is an EMR, EHR, PHR, HIE, RHIO etc. The consensus definition work of NAHIT and AHIMA was presented to AHIC last week. Although not everyone will agree with these definitions, they are starting point. At AHIC one public comment illustrated the problem of legacy definitions - NextGen markets its product as the NextGen EMR. Does that mean it is inferior to the eClinicalWorks EHR, since an EHR is defined as standards-based and interoperable, while an EMR is defined as a single institution's standalone record. At BIDMC, we're providing a community EHR, we have an institutional EHR called webOMR (Online Medical Record), and a PHR called Patientsite. Patientsite is fully interactive with multiple data sources and Google Health, so we can continue to call it a PHR per the definition below. Here's the summary of the NAHIT work:

Electronic Medical RecordAn electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization.

Electronic Health RecordAn electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff, across more than one health care organization.

Personal Health RecordAn electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual.

Health Information ExchangeThe electronic movement of health-related information among organizations according to nationally recognized standards. HIE is a verb describing a process.

Health Information OrganizationAn organization that oversees and governs the exchange of health-related information among organizations according to nationally recognized standards. HIO is a noun describing an organization.

Regional Health Information OrganizationA health information organization that brings together health care stakeholders within a defined geographic area and governs health information exchange among them for the purpose of improving health and care in that community

Monday, June 9, 2008

Each year when I publish the IT operating plan summary, I'm careful to relate the projects to their strategic importance, impact on patients, improvements in quality/safety, and return on investment.

This was nicely stated by Ian Furst who commented on my blog about Marketing IT. He noted that a statement such as "Our goal is to be 100% computerized by 2009" sounds like an IT goal. Ideally, goals should start with "we will improve the patient care/experience/life expectancy with....."

To align Clinicians and IT, I have a Clinical Information Systems Steering Committee which includes membership from 11 subcommittees:

The work of all these committees was recently presented to the Clinical Operations Coordinating Committee, the joint administrative/clinician governance of BIDMC. The presentation I used illustrates the major clinical accomplishments for FY08, the goals for FY09 and plan for future years. Each slide describes the clinical benefit of the projects.

When I execute complex clinical projects each year, I'm typically asked three questions about my approach to aligning clinicians and IT.

Every project must start with a charter that identifies the stakeholders, roles/responsibilities, the purpose of the project, the milestones, and metrics for success. The only way to balance scope, timing, and resources is to have an unambiguous definition of who cares about the project, who does the work, why the project will be done, when the project will be done, and how project success is defined. As the project proceeds there will be many requests to expand its scope, add more features, increase the number interfaces, and expand the the stakeholder population being served. The committee providing governance to the project, guided by the charter, must resist the change in scope. If change in scope is deemed critical to the project's success then the charter should be changed to reflect the impact on project timing and resources, ensuring that change is broadly communicated.

What are the biggest mistakes?

Projects must ultimately be driven by their business owners, such as the doctors, nurses and staff who will be using the finished system, not by IT. Having clinician driven projects ensures the application becomes "the clinician's system" and not the "IT system which administration forced on us". Also, software should not be used to change workflow. Before implementation of the software, business processes should be optimized and workflow documented. Then, software can automate that workflow. If software is used to force behavioral change, clinicians will blame the software for any frustrations they have about the process change.

What are the top 3 best practices to ensure success?

Big bang IT never works. Pilots and phased implementation of applications reduces the risk of failure and ensures the resources are available to respond to any infrastructure or application issues which occur during roll out.

Broadly communicating the benefits of the project and the urgency to implement it really helps with clinician acceptance/adoption.

Project management is key. Ensuring the scope is constrained, milestones achieved, and participants coordinated are prerequisites to a successful project.

As a clinician myself, I use the systems we create. Being a physician CIO/CMIO helps me understand the clinical impact of every project, engage the clinicians in every project, and establish trust with all the doctors and nurses in the hospital.

By July 1, 2008, we'll pilot the tools and technologies needed to make this happen.

What will we launch on that date? Call it Facebook meets eHarmony for the Harvard community.

The Catalyst portal brings together numerous federated databases at Harvard into a new social networking application. It's the Cool Technology of the Week and here's how it works.

Harvard has a basic faculty database that includes information about every faculty member, such as their title, institutional affiliation, and email address. We can use that email address to match data feeds from the 17 affiliated Harvard hospitals and provide additional hospital specific information about each faculty member.

A person directory with email, phone and address sounds like bread and butter IT. Here's the cool part. We use the demographic information of each faculty member to connect to the National Library of Medicine's PubMed repository via web services. PubMed returns a list of all the publications of the faculty member plus all the Medical Subject Headings (MeSH terms) associated with each publication. We can then use these terms to map the interests of each person and compare these interests to every other Harvard faculty member (that's the eHarmony part). From the screen capture above, you can see a listing of my Keywords, my co-Authors and the Similar People to me. I can then click on people like me, read their Profile pages, and describe my relationship to them (that's the Facebook/LinkedIn/Plaxo part). I can also see all my advisors, advisees, and departmental colleagues and connect to them in one click.

People profiles and collaborators is just one aspect of Catalyst. It also includes Matchmaking to find skills and resources based on declared areas of expertise.

It includes an overview of all the Research Cores throughout Harvard, their scope, and contact information.

It includes Harvard-wide Events and Conferences in one easy to use cross-organizational interface.

It includes an Atlas of every associated institution's maps, phone numbers, and websites.

Finally, it includes SHRINE, an innovative, web-services based federated data mining tool that enables clinical research among all the data at all Harvard hospitals with appropriate privacy protection and IRB oversight. This infrastructure is so revolutionary that I will write a separate blog entry about it.

Thursday, June 5, 2008

I've blogged about my vision of a Greener lifestyle including a Vegan diet, an ecofriendly home, and green data centers.

Part of my effort to do the right thing to protect my daughter's future is being a "locavore", eating food grown or harvested nearby using sustainable farming methods. Admittedly this is challenging in New England, which has 6 months of winter.

At Google's Mountain View headquarters, "Cafe 150" serves only food which is grown within 150 miles of Google. Since some of the most fertile growing areas in the country with year long growing seasons are nearby, it's possible to have sustainable, organic, local foods every day.

What do we do in New England? We can join a CSA such as Red Fire Farm.

CSA stands for Community Supported Agriculture.

The idea is that participants buy into the farm at the beginning of the growing season and receive a share of the harvest. Shares are distributed each week from June through October. With the funds contributed, the local farmer grows sustainable, organic produce without chemicals, pesticides, or herbicides. The CSA approach creates local jobs, collaboration between consumers and the farmer, and is an alternative to detrimental industrial food producers from distant regions.

One share provides all the vegetables needed for a family of 4 for a harvest season. As vegans, we buy two shares, since our diet consists entirely of vegetables, fruits and grains.

Wednesday, June 4, 2008

To me, the basic components of a medical record are Problems, Medications, Allergies, Notes/Reports, Lab/Micro Results, and Radiology results including images. Of all of these, image exchange between different vendor systems and among organizations is the most problematic. Standards exist to transmit the outputs of CT, MRI, Ultrasound and digital xray machines to PACS systems, but most vendors customize or extend the standards to meet their own proprietary needs. Sharing images among providers is essential for coordination of care and efficiency. The path forward to enable image sharing across vendors, modalities, and imaging technologies is not entirely clear.

Creating an archive of all image types used within an organization seems like a logical first step. I've written about the technologies to do this (Cool Technology of the Week ), which involve placing images from all departments into centralized storage devices (NAS, Data Domain appliances, tape or optical disk juke boxes) then storing metadata about the images in data repository which can be accessed by an image viewer which works with all image types.

However, there are multiple possible approaches. General Electric offers an Enterprise Archive product that is capable of managing images from multiple modalities as long as they are DICOM-based. (GE's product can manage multiple image types: jpeg, jpeg2000, DICOM, etc. in the long-term archive. However, if using their PACS Workstations, and/or Web viewer, it must be converted into a DICOM image, if it was not originally acquired in DICOM.) Teramedica's product uses a Service Oriented Architecture to retrieve DICOM and non-DICOM files from storage devices.

It's an interesting issue. On the one hand GE is correct - DICOM is the universal standard for image management in healthcare. Utilities are available that can turn other image formats, such as JPEG, GIF and TIF, into DICOM objects. A standard DICOM viewer from GE, Merge-Efilm, or other third party should work reasonable well with DICOM formats.

On the other hand, are Flickr, Facebook and Myspace using DICOM for image management? In the world of web 2.0, you'll find technologies like SOAP/XML for managing metadata and industry standard image formats such as JPEG for storing images.

Who will win - DICOM for all healthcare images OR a flexible service oriented approach to using DICOM for some images and JPEG for others?

We're continuing to investigate the pros and cons. My prediction is that as more and more hospitals discover the importance of unified image management, multiple companies with various technology approaches will enter the marketplace. Teramedica is an early entrant with technologies that enable migration of images among different storage devices, compression based on business rules, and image deletion by replacing large DICOM objects with a small object that when viewed presents a simple graphic stating "Image deleted by policy". GE claims its approach is high performance and ensures data integrity. IBM has its GMAS product which offers a grid of storage for image management. I'm sure that Siemens, McKesson and other PACS vendors will follow soon with their products.

My advice is to assess the features needed in your institution to accomplish image viewing and archiving within the built and bought systems you have. Define the workflow needed by your users. Determine what dependency the archive creates on a single vendor i.e. if the vendor goes out of business or discontinues its product, what will your options be? Joe Marion's blog entry will help you understand the issues.

In the meantime, I'm working at the national level via the 2008 HITSP "Consultations and Transfers of Care" use case which requires we constrain the optionality of DICOM to enable exchange of images as part of a patient's lifetime medical summary. Reducing variability of DICOM will better support plug and play interoperability of images among different vendors.

In 2008, BIDMC's plan is to learn about all the approaches, convene the vendors together, and determine what is possible. You can be sure I'll share those vendor discussions with you via my blog as they happen.

Tuesday, June 3, 2008

As promised, it's June and BIDMC has begun the implementation of our Software as a Service Electronic Health Record for non-owned clinicians. As we "market" the practices on the idea of using a hospital subsidized electronic health record, we need to have all the details ready - the costs, the service levels, and a crisp definition of the roles and responsibilities of each member of our team. Since the project is comprised of 5 insourced and outsourced groups working seamlessly together (BIDMC, Massachusetts eHealth Collaborative, eClinicalWorks, Concordant, and Third Brigade), we need to have unambiguous agreement among our teams as to who will do what, who will be accountable and who will communicate the handoffs.

To ensure a perfect understanding among all stakeholders, we created a Roles and Responsibilities Matrix. There are two aspects of this work that are generally useful to other hospital systems implementing electronic health records.

1. We've defined all the component parts of an implementation, from training, to desktop support, to security

2. We've classified the roles asResponsible - the person or team who does the workAccountable - the person or team who reports on the work and is ultimately held responsible for its completionConsulted - the person or team who provides an opinion when consulted as a stakeholderInformed - the person or team who is told about the decisions made and progress achieved

Each of the 5 team members will sign of on the matrix so that there will be no misunderstandings or finger pointing.

When implementing large, complex projects, adding extra details like a roles and responsibility matrix prevent future problems. Assumptions can get teams into trouble. Well documented understandings keep everyone friendly. I hope you find it useful.

HITSP worked with the Center for Medicare and Medicaid services (CMS) to ensure IS07 is consistent with the ePrescribing federal initiative led by CMS including adherence to standards required for ePrescribing under Part D of the Medicare Modernization Act (MMA)

IS07 uses the version of the NCPDP SCRIPT Standard Implementation Guide cited in MMA (currently Version 8.1) in most circumstances and Version 10.1 to include specialized data elements not included in Version 8.1 . To obtain and exchange local patient identifiers for communication between prescriber, dispenser, and payer organizations, IS07 defined a bridge between standards typically used in prescriber settings (HL7) with those typically used in payer and dispenser settings (NCPDP and X12N)

For exchange of a patient’s medication history, IS07 uses standards consistent with MMA to exchange medication history detail (NCPDP SCRIPT) and standards to include medication history in a clinical summary that also includes allergies, problem lists, etc. (HITSP C32, the Continuity of Care Document)

These standards are mature and already are widely used. Given the maturity of e-Prescribing standards, I signed a letter to Congress supporting the Medicare Electronic Medication and Safety Protection Act of 2007, noting that standards are no longer a barrier to medication management and e-prescribing.

I'll also present "Document reliable interchange", HITSP Technical Note T31, which provides a standards-based mechanism for exchanging medical documents securely over a network. This includes interchange among EHRs, PHRs, Quality Measurement Organizations, Public Health Authorities and other healthcare IT systems. This simplified document exchange and sharing mechanism does not require the use of XDS, the document sharing infrastructure described by the Integrating the Healthcare Enterprise (IHE) IT Infrastructure Technical Framework. Instead it uses IHE Cross-Enterprise Document Reliable Interchange (XDR) Integration Profile, which is very easy to implement.

In the current Beth Israel Deaconess pilot project with the Social Security administration to exchange medical records for disability benefits adjudication, we will be using this set of standards. T31 provides the specifics to use SOAP and HTTPS, mature standards that are used for many web 2.0 data exchanges.

If I were to forecast where all this standards effort is leading, over the next few years, I'd summarize our progress as

2007 *Standardize point to point messaging by harmonizing the work standards development organizations have done for the past 10 years*Standardize security

2009 Continue to add data elements to the CCD/CD Document Summary*Further consolidate vocabularies used across SDOs*SDOs begin developing standards collaboratively so that they arrive at HITSP with some pre-harmonization

2010*Vendor products produced with document exchange and security constructs built in*Regional exchanges built with these standards

It's a great time for standards in the US and I believe the 500 organizations in HITSP are making a real difference on the path toward interoperability.